M.R.SHOJA1 GOOD MORNING & CONGRATULATION. M.R.SHOJA2 Professor Of Ophthalmology

M.R.SHOJAM.R.SHOJA 11

GOOD MORNING &GOOD MORNING & CONGRATULATION CONGRATULATION


M.R. SHOJAM.R. SHOJAProfessor Of Professor Of Ophthalmology Ophthalmology


BACTERIAL KERATITISBACTERIAL KERATITIS

An ocular emergencyAn ocular emergency

Prompt diagnosisPrompt diagnosis

Initiation of approtiate antibioticInitiation of approtiate antibiotic

Limit amount of tissue destructionLimit amount of tissue destruction

Improve patient,s visual prognosisImprove patient,s visual prognosis


Most important defense Most important defense barrier for cornea is intact barrier for cornea is intact epithelial layerepithelial layer

Major risk factors for infectious Major risk factors for infectious keratitis is compromised keratitis is compromised epithelium protective layer .epithelium protective layer .

Precipitating event is epithelial Precipitating event is epithelial defect produced by trauma, defect produced by trauma, contact lens wear or a chronic contact lens wear or a chronic corneal disorderscorneal disorders

Ocular Ocular DefenseDefense

Mechanism Mechanism

Chemical Chemical Mechanical Mechanical

Abnormality of tear filmAbnormality of tear film

Lysozym

Lactoferin

immunoglubulinA

Mucin deficiency

• Intact corneal epitheliuma

(first line of defence)

• Blinking reflex

• (reduced bacterial colonization)


Pathogenesis

Proliferation of Bacteria

Adherence to ulcerated epithelium

invasion into stroma

Migration of neutrophile Production of proteinase

Inflammatorynecrosis

Neovascular scar formation Corneal perforation


RiskRisk factorsfactors (Corneal)(Corneal)

TraumaTrauma Contact lens wearContact lens wear Previous ocular surgeryPrevious ocular surgery Ocular adnexal disordersOcular adnexal disorders Chronic surface disease of Chronic surface disease of

corneacornea Decreased corneal sensation Decreased corneal sensation

Risk Risk Factors Factors

SystemicSystemicconditioncondition LocalLocal

• Diabetes• Systemic infections• Collagen vascular diseases• Immuno suppressive drug• Pregnancy• Chronic alcholism• Extensive body burns• Drug addiction• AIDS

Topical: Steroid Antiviral

Antibiotic Anesthestics


Chronic Corneal Chronic Corneal Surface Disease Surface Disease

Bullous keratitisBullous keratitis

Exposure keratopathyExposure keratopathy

Keratoconjunctivitis siccaKeratoconjunctivitis sicca

Neurotrophic keratopathy Neurotrophic keratopathy


Previous ocular surgeryPrevious ocular surgery Cataract extractionCataract extraction

KeratoplastyKeratoplasty

Pterygium excisionPterygium excision

Loose corneal suturesLoose corneal sutures

Refractive surgeryRefractive surgery


Ocular Adnexal ConditionsOcular Adnexal Conditions

EntropionEntropion

EctropionEctropion

TrichiasisTrichiasis

Blepharitis / Blepharitis / RosaceaRosacea


Normal flora of ocular surfaceNormal flora of ocular surface GRAM POSITIVE:GRAM POSITIVE: Staphylococcus Aureus (more common)Staphylococcus Aureus (more common) Staphylococcus Epidermidis (more common)Staphylococcus Epidermidis (more common) Propionibacterium acnes.Propionibacterium acnes. Streptococcus ViridansStreptococcus Viridans GRAM NEGATIVEGRAM NEGATIVE (less common) (less common) Escheria ColiEscheria Coli KlebsiellaKlebsiella ProteusProteus MoraxellaMoraxella


Causes of Bacterial keratitis Causes of Bacterial keratitis (87%)(87%)

Staphylococcus aureus Staphylococcus aureus

Staphylococcus epidermidisStaphylococcus epidermidis

Streptococcus pneumonieaStreptococcus pneumoniea

Pseudomonas aeruginosa Pseudomonas aeruginosa

Most common organism in soft contact Most common organism in soft contact lenslens

Enterobacteriaceae Enterobacteriaceae (proteus, (proteus, enterobacter)enterobacter)


Now yorkNow york LondonLondon

S.aureus S.aureus S.aureusS.aureus Pseudomonas Moraxella Pseudomonas Moraxella S.pneumonia S.pneumonia PseudomonasPseudomonas

ETIOLOGY


OrOrgganismsanisms penetrate intact penetrate intact epitheliumepithelium

Neisseria gonorroae Neisseria gonorroae

Haemophilus agegyptius Haemophilus agegyptius

Corynebacterium diphteria Corynebacterium diphteria

Listeria Listeria


Clinical presentationClinical presentation

Rapid onset of painRapid onset of pain Conjunctival injection (Conjunctival injection (RednessRedness)) PhotophobiaPhotophobia Decreased visionDecreased vision Discharge and lid edemaDischarge and lid edema


Clinical features of GClinical features of G++ & G & G-- keratitis keratitis

Feature Feature Gram positiveGram positive Gram Gram negativenegative

AppearanceAppearance Mild to dense Mild to dense infiltrateinfiltrate

Dense infiltrate Dense infiltrate necrosisnecrosis

BordersBorders Distinct infiltrate Distinct infiltrate bordersborders

Indistinct bordersIndistinct borders

Surrounding Surrounding cornea hypopyon cornea hypopyon

Generally clear less Generally clear less commoncommon

Often hazy more Often hazy more commoncommon


CORNEAL PERFORATIONCORNEAL PERFORATION

IN PSEUDOMONAS & GONOCOCCAL KERATITIS.IN PSEUDOMONAS & GONOCOCCAL KERATITIS.

SYMPTOMS:SYMPTOMS:

SUDDEN LOSS OF HYPOPYONSUDDEN LOSS OF HYPOPYON

RADIAL FOLD IN DESCEMET MEMBRANERADIAL FOLD IN DESCEMET MEMBRANE

PROTRUSION OF CORNEA AND PROTRUSION OF CORNEA AND

DESMATOCELE FORMATION.DESMATOCELE FORMATION.

TREATMENT:TREATMENT:

PATCH GRAFT OR PATCH GRAFT OR

PENETRATING K.PENETRATING K.


PseudomonasPseudomonas Keratitis (G Keratitis (G --)) Most common in Scls wearMost common in Scls wear,burn ,comatose , ,burn ,comatose ,

mechanicalmechanical respiratory patients. respiratory patients. Yellowish green hue with resistant to Yellowish green hue with resistant to

treatment.treatment.

Most common in childrenMost common in children << 3 years 3 years Contaminant in hospital, fluoresnce Contaminant in hospital, fluoresnce solutions.solutions.

Rapidly progressive,destructive keratitis.Rapidly progressive,destructive keratitis. May cause infectious Scleritis.May cause infectious Scleritis. Within 24-48 h perforation may occur.Within 24-48 h perforation may occur. Systemic antibiotic is necessary.Systemic antibiotic is necessary.


Gonococci KeratitisGonococci Keratitis

Hyperacute conjunctivitis , preauricular Hyperacute conjunctivitis , preauricular adenopathyadenopathy

PPenetrate intact epithelium ,produce rapid enetrate intact epithelium ,produce rapid corneal ulceration and perforation as 24 to corneal ulceration and perforation as 24 to 48 hours after infection.48 hours after infection.

Choice of treatment is 1 g ceftriaxone IM or Choice of treatment is 1 g ceftriaxone IM or IV for 3 to 5 days for keratitis.IV for 3 to 5 days for keratitis.

Frequent irrigation is necessary.Frequent irrigation is necessary. Sexual partners should be evaluated.Sexual partners should be evaluated. In all hyperacute conjunctivitis the entire In all hyperacute conjunctivitis the entire

cornea must be evaluated for ulcerationcornea must be evaluated for ulceration


Gonococci CGonococci Conjunctivitisonjunctivitis & &

KeratitisKeratitis


Clinical signs of Clinical signs of resolutionresolution

Improved patient comfortImproved patient comfortProgressive re-epithelialization over infiltrate Progressive re-epithelialization over infiltrate Decreasing size and density of infiltration.Decreasing size and density of infiltration.Loss of adherent mucopurulent dischargeLoss of adherent mucopurulent dischargeReduction in hypopyon Reduction in hypopyon Reduction of stromal edema surrounding Reduction of stromal edema surrounding

infiltrateinfiltrateDevelopment of well-defined infiltrate Development of well-defined infiltrate

bordersborders


Stain or culture media Stain or culture media

StainsStains Gram stainGram stain Giemsa stainGiemsa stain Calcofluor white stainCalcofluor white stain Acid fast stainAcid fast stain

Culture mediaCulture media Blood agarBlood agar Sabourauds agarSabourauds agar Chocolate agarChocolate agar Thioglycolate brothThioglycolate broth


Goals of therapyGoals of therapy Rapid elimination of bacteriaRapid elimination of bacteria Reduction of inflammatory Reduction of inflammatory responseresponse Prevent of structural damagePrevent of structural damage Promotion healing of epithelial Promotion healing of epithelial


Treatment

Hospitalization

Systemic Antibiotic Corneal Graft

Fortified combined drops

Monotherapy Fluroquinolone

Drug penetartion in to cornea increased with higher concentration and frequent application


Treatment Treatment ((ImpricalImprical))

Loading dose : 5 application every 2 Loading dose : 5 application every 2 MinMin

Frequent instillation every 30 MinFrequent instillation every 30 Min

Fortified cephalosporin (Fortified cephalosporin (50mg/dl) +50mg/dl) +

gentamycin or tobramycin (gentamycin or tobramycin (15mg/ml)15mg/ml)

Modification of initial AB is based on Modification of initial AB is based on culture results and clinical responseculture results and clinical response

For (G +) Vancomycin is alternativeFor (G +) Vancomycin is alternative

For (G-) Ceftazidime or AmikacineFor (G-) Ceftazidime or Amikacine


Initial therapy for bacterial keratitisInitial therapy for bacterial keratitis

OrganismOrganism Antibiotic Antibiotic Topical Topical dose dose

Gram- positive cocciGram- positive cocci CefazolinCefazolin

Vancomycin *Vancomycin *50 mg/ml50 mg/ml

50 mg/ml50 mg/ml

Gram- negative rodsGram- negative rods TobramycinTobramycin

Ceftazidime Ceftazidime

Gentamycin Gentamycin

9-14 9-14 mg/mlmg/ml

50 mg/ml50 mg/ml

14 mg/ml14 mg/ml

No organism or No organism or

multiple types of organismsmultiple types of organismsCefazolin With Cefazolin With

Tobramycin orTobramycin or

FluoroquinolonesFluoroquinolones

50 mg/ml50 mg/ml

3 mg/ml3 mg/ml

Gram-negative cocciGram-negative cocci Ceftriaxone Ceftriaxone

ceftazidimeceftazidime50 mg/ml50 mg/ml

50 mg/ml50 mg/ml


AntibioticsAntibiotics The choice of antibiotics is standard The choice of antibiotics is standard

topical, commercially unavailable, topical, commercially unavailable, fortified aminoglycoside and fortified fortified aminoglycoside and fortified cephalosporin drops (ie gentamicin 1.5% cephalosporin drops (ie gentamicin 1.5% and cefuroxime 5%) or the new regime and cefuroxime 5%) or the new regime of fluoroquinolone monotherapy with of fluoroquinolone monotherapy with commercially available ciprofloxacin or commercially available ciprofloxacin or ofloxacin 0.3%.ofloxacin 0.3%.

Currently both the standard and Currently both the standard and fluoroquinolone regimen encounter fluoroquinolone regimen encounter bacterial resistance in about 5% of casesbacterial resistance in about 5% of cases


TreatmentTreatment

Subconjunctival injectionSubconjunctival injection for for impending corneal perforationimpending corneal perforation

Hydrophilic soft contact lensHydrophilic soft contact lens ParenteralParenteral 1-Impending perforation1-Impending perforation 2-Perforated infection2-Perforated infection 3-Scleral involvement3-Scleral involvement


•Not to be use in initial phase

•Favourable response to antibiotic is advised.

•Prednisolone acetate 1% QID

•Patient must have frequent follow-up

Topical

Corticosteroid

Inhibit chemotaxis & phagocytosis

Recurrent of

infection

Reduced stromal inflammatory reaction

Limit tissue destruction by PMN and neovascuarization with scar


Corneal ExposureCorneal Exposure


Corneal MeltCorneal Melt


Corneal UlcerCorneal Ulcer


Hypopion UlcerHypopion Ulcer

Fungal KeratitisFungal Keratitis

Fungal keratitis is challenging corneal Fungal keratitis is challenging corneal disease and presents as very difficult form disease and presents as very difficult form bacterial keratitis. Difficulty arise in making bacterial keratitis. Difficulty arise in making correct clinical and laboratory diagnosis. The correct clinical and laboratory diagnosis. The treatment of fungal keratitis is also difficult treatment of fungal keratitis is also difficult due to poor availability of antifungal drugs due to poor availability of antifungal drugs and delay in starting treatment. and delay in starting treatment.

Treatment is required on long term basis, Treatment is required on long term basis, intensively and often cases require intensively and often cases require therapeutic keratoplasty. therapeutic keratoplasty.

3535M.R.SHOJAM.R.SHOJA


Fungi enter into corneal stroma through Fungi enter into corneal stroma through epithelial defect, which may be due to epithelial defect, which may be due to trauma, contact lens wear, bad ocular trauma, contact lens wear, bad ocular surface or previous corneal surgery.surface or previous corneal surgery.

In stroma fungi multiply and causes tissue In stroma fungi multiply and causes tissue necrosis and inflammatory reaction.necrosis and inflammatory reaction.

Organisms enter deep into the stroma and Organisms enter deep into the stroma and through an intact Descemets membrane through an intact Descemets membrane into the anterior chamber and iris. They into the anterior chamber and iris. They can also involve Sclera. can also involve Sclera.


Risk FactorsRisk Factors

1.1. Trauma outdoor/ or the one which Trauma outdoor/ or the one which involves plant matter (including contact involves plant matter (including contact lenses)lenses)

2.2. Topical medications:Topical medications:

3.3. corticosteroids, corticosteroids,

4.4. anaesthetic drug abuse anaesthetic drug abuse

5.5. topical broad spectrum antibiotics use topical broad spectrum antibiotics use for long timefor long time


Risk FactorsRisk Factors

6. Systemic use of steroids 6. Systemic use of steroids

7. Corneal surgeries (Penetrating keratoplasty, 7. Corneal surgeries (Penetrating keratoplasty, refractive surgery)refractive surgery)

8. Chronic keratitis (herpes simplex, herpes 8. Chronic keratitis (herpes simplex, herpes zoster, Vernal or allergic keratoconjunctivitis, zoster, Vernal or allergic keratoconjunctivitis, and neurotrophic ulcer) and neurotrophic ulcer)

9. Diabetes , Chronically ill / hospitalised 9. Diabetes , Chronically ill / hospitalised patients, AIDS and leprosypatients, AIDS and leprosy


Causative fungi Causative fungi

I.I. Yeast: Candida species (albicans), Yeast: Candida species (albicans), CryptococcusCryptococcus

II.II. Filamentous septated Filamentous septated A. Non-pigmented hyphae: Fusarium A. Non-pigmented hyphae: Fusarium species (solani), Aspergillus species species (solani), Aspergillus species (fumigatus, flavus, niger)(fumigatus, flavus, niger)


Causative fungiCausative fungi

III. Filamentous non-septated : III. Filamentous non-septated : Mucor and Rhizopus species Mucor and Rhizopus species

IV. Diphasic forms: Histoplasma, IV. Diphasic forms: Histoplasma, Coccidiodes, BlastomycesCoccidiodes, Blastomyces


SymptomsSymptoms

Onset is slowOnset is slow Symptoms are less compared to Symptoms are less compared to

signssigns Diminution of vision, pain, foreign Diminution of vision, pain, foreign

body sensation body sensation


SignsSigns

Diminution of vision, depending on Diminution of vision, depending on location of ulcerlocation of ulcer

Conjunctival and ciliary congestionConjunctival and ciliary congestion Epithelial defectEpithelial defect Stromal infiltratesStromal infiltrates Elevated areas, hypate (branching) Elevated areas, hypate (branching)

ulcers, irregular feathery marginsulcers, irregular feathery margins Dry and rough texture Dry and rough texture


Fungal Keratitis with Fungal Keratitis with HypopyonHypopyon


SignsSigns

Satellite lesionsSatellite lesions Brown pigmentation due to Brown pigmentation due to

dematiaceous fungus (Curvularia dematiaceous fungus (Curvularia lunata)lunata)

Intact epithelium with stromal Intact epithelium with stromal infiltratesinfiltrates

Anterior chamber reaction Anterior chamber reaction



Fungal Keratitis – Pigmented Lesion


Case of Fungal+ Case of Fungal+ Bacterial KeratitisBacterial Keratitis


Laboratory DiagnosisLaboratory Diagnosis

The Gram and Giemsa stains are used as The Gram and Giemsa stains are used as initial stains initial stains

Potassium Hydroxide (10-20 %) wet Potassium Hydroxide (10-20 %) wet mounts mounts

Culture Media: Sheep blood agar, Culture Media: Sheep blood agar, Chocolate agar, Sabouraud dextrose agar, Chocolate agar, Sabouraud dextrose agar, Thioglycollate broth Thioglycollate broth

Anterior chamber tap under aseptic Anterior chamber tap under aseptic conditions to aspirate hypopyon and or conditions to aspirate hypopyon and or endothelial plaqueendothelial plaque


TreatmentTreatment

Natamycin 5% suspension: Natamycin 5% suspension: Candida species respond better to Candida species respond better to Amphotericin B 0.15%Amphotericin B 0.15%

Fluconazole 2%Fluconazole 2% Miconazole 1%Miconazole 1% Scrapping every 24 to 48 hours Scrapping every 24 to 48 hours Treatment is required for 4 – 6 Treatment is required for 4 – 6

weeks weeks


TreatmentTreatment

Sub-conjunctival injection of Sub-conjunctival injection of Miconazole 5 – 10 mgm of 10 mgm/ml Miconazole 5 – 10 mgm of 10 mgm/ml suspension (indicated in severe form suspension (indicated in severe form of keratitis, scleritis and of keratitis, scleritis and endophthalmitis) endophthalmitis)

Systemic: Systemic:

Fluconazole or Ketoconazole is Fluconazole or Ketoconazole is indicated in severe form of keratitis, indicated in severe form of keratitis, scleritis and endophthalmitisscleritis and endophthalmitis


Surgical TreatmentSurgical Treatment

1.1. Daily debridement with spatula/ blade every Daily debridement with spatula/ blade every 24 – 48 hours 24 – 48 hours

2.2. Surgical treatment is required in Surgical treatment is required in approximately 1/3approximately 1/3rdrd cases of fungal keratitis cases of fungal keratitis due to failure of medical treatment or due to failure of medical treatment or perforation perforation

3.3. Surgical treatment in the form of :Surgical treatment in the form of :therapeutic keratoplasty, conjunctival flap or therapeutic keratoplasty, conjunctival flap or lamellar keratoplasty lamellar keratoplasty


Surgical TreatmentSurgical Treatment

Surgery is usually indicated within 4 Surgery is usually indicated within 4 weeks due to failure of medical weeks due to failure of medical treatment or recurrence of infection treatment or recurrence of infection

Unfavorable outcome is due to scleritis, Unfavorable outcome is due to scleritis, endophthalmitis and recurrence endophthalmitis and recurrence

Cryotherapy with topical antifungal Cryotherapy with topical antifungal treatment or corneoscleral graft in cases treatment or corneoscleral graft in cases of fungal scleritis and keratoscleritis of fungal scleritis and keratoscleritis


Viral KeratitisViral Keratitis

Herpes SimplexHerpes Simplex Herpes ZosterHerpes Zoster

Large dendrites with central ulceration and terminal bulbs

Small, medusa-like dendrites WITHOUT central ulceration or terminal bulbs

Herpes Simplex Keratitis:Herpes Simplex Keratitis:PathogenesisPathogenesis

HSV is a DNA virus that commonly HSV is a DNA virus that commonly infects humansinfects humans

Two distinct strains existTwo distinct strains exist– HSV-1: orofacial and ocularHSV-1: orofacial and ocular– HSV-2: orogenital STD, neonatalHSV-2: orogenital STD, neonatal

Recurrent HSV keratitis is one of the Recurrent HSV keratitis is one of the most frequent causes of infective most frequent causes of infective corneal blindness in the UScorneal blindness in the US

Herpes Simplex Keratitis:Herpes Simplex Keratitis:Primary Ocular InfectionPrimary Ocular Infection

Most commonly occurs on the Most commonly occurs on the mucocutaneous areas of the head mucocutaneous areas of the head innervated by CN Vinnervated by CN V

Manifests as a nonspecific URIManifests as a nonspecific URI May travel to the sensory ganglion and May travel to the sensory ganglion and

remain in a latent nonpathogenic stateremain in a latent nonpathogenic state

HSV:Primary Ocular Infection:HSV:Primary Ocular Infection:Clinical PresentationClinical Presentation

Unilateral vesicular Unilateral vesicular blepharokeratoconjunctivblepharokeratoconjunctivitisitis

Follicular conjuntivitis Follicular conjuntivitis with occasional with occasional membrane formationmembrane formation

Cutaneous vesicles on Cutaneous vesicles on eyelid skin or margineyelid skin or margin

Preauricular nodesPreauricular nodes 2/3 develop epithelial 2/3 develop epithelial

keratitiskeratitis

HSV: Primary Ocular InfectionHSV: Primary Ocular InfectionTreatmentTreatment

Self-limited conditionSelf-limited condition Topical antiviral therapyTopical antiviral therapy

– Trifluridine (Viroptic)Trifluridine (Viroptic)– Vidarabine Vidarabine

Oral antiviral therapy (one week)*Oral antiviral therapy (one week)*– Acyclovir 400mg 5x/dayAcyclovir 400mg 5x/day– Famcyclovir 500mg 3x/dayFamcyclovir 500mg 3x/day*may reduce recurrence rate*may reduce recurrence rate

Documents

M.R.SHOJA1 GOOD MORNING & CONGRATULATION. M.R.SHOJA2 Professor Of Ophthalmology